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Sarah Schweiss, Pharm.D. Ambulatory Care Resident University of Minnesota & Duluth Clinic January 18 th, 2010
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Discuss general information and consequences of uncontrolled ADHD. Review potential causes, the clinical presentation, and the diagnosis of ADHD. Outline pharmacological and non- pharmacological treatment options for ADHD. Discuss fiction, facts, and controversies surrounding ADHD. Briefly discuss prescription drug abuse statistics, consequences, and prevention methods.
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3-7% school-age children Diagnosis occurs as early as age 3 Average age of diagnosis:_____ Up to 60% of children continue to have significant symptoms into adulthood Males>>Females (3:1) Number of people diagnosed with ADHD has increased by an average of 3% each year between 1997-2006 (CDC)
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Relationship difficulties Academic failure Social isolation Involvement with deviant peer groups Significantly greater risk of developing: ___________________________________ Low self-esteem
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Currently - no one identified cause of ADHD Hypothesized to be caused by a combination of environmental and genetic factors Imbalance between neurotransmitters in the brain Norepinephrine Dopamine Genetics Parent with ADHD = _____% chance of developing ADHD Monozygotic twins have up to a ___% concordance rate Environmental exposures Maternal smoke or alcohol use
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DSM-IV criteria Symptoms present prior to age 6 y.o. Must involve 2 environments, e.g., school & home Patients must meet > 6 symptoms in the categories of impulsivity, inattention, and/or hyperactivity Social, academic or occupational functioning is impaired Other psychiatric illnesses are ruled out
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Lack of attention to details Difficulty sustaining attention and organizing Avoids tasks Difficulties listening Does not follow through on instructions Easily distracted Forgetful in daily activities Loses things necessary for activities
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Fidgets and/or squirms Leaves seat when prohibited Runs or climbs excessively at inappropriate times Difficulties playing quietly Often “on the go” Excessive talking Blurts out answers before completion of question Interrupts and/or intrudes Difficulty waiting to take turns
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Pharmacological Psychostimulants Non-stimulants Non-pharmacological Behavioral Interventions Counseling/Talk Therapy Focused help with schoolwork Training for parents
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Behavioral Interventions Positive reinforcement Time-out Response Cost Token economy Parent training Family therapy Classroom interventions Contingency management
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Psychostimulants Non-stimulants
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Methylphenidate - FDA approved for >6 yo Immediate Release: Ritalin®, Methylin®, methylphenidate Intermediate Acting: Ritalin SR®, Methylphenidate SR, Metadate ER, Methylin ER Sustained Release: Metadate CD, Ritalin LA, Concerta Dexmethylphenidate (Focalin®) – >6 yo Dextroamphetamine (Dexedrine®,Dextrostat®) >3yo Dextroamphetamine/Amphetamine (Adderall® & Adderall XR) >3yo Desoxyephedrine/methamphetamine (Desoxyn ®) >6yo Lisdexamfetamine (Vyvanse ®) >6yo
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Increase norepinephrine and dopamine in the brain synapse May take __________ for the medication to begin working Efficacy ranging from 70% to 96%
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Dosing schedules differ because duration of medications vary Immediate Release: Medication effects last approximately 2-6 hours Usually 2-3 times/day dosing schedule Intermediate Acting: Medication effects last approximately 6-8 hours Usually twice daily dosing Sustained Release: Medication effects last approximately 8-12 hours Once daily dosing
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Increased attention span Decreased hyperactivity Improved impulse control Social benefits Emotional stability Improved motor skills (i.e., handwriting)
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Common Side EffectsRecommendation Reduced appetite, weight loss Stomach ache Insomnia Headache Rebound Symptoms Irritability/jitteriness
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Uncommon to rare Dysphoria Zombie-like state Tics or abnormal movements High blood pressure Hallucinations
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Empty, labeled bottle for school Keep out of sight & reach from other children Take with food or milk Start on the weekend while parents able to observe for any adverse effects Start once a day, then increase to twice a day (typically breakfast & lunch) Swallow whole, DO NOT CHEW
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Important to reassess treatment All children should be given a drug-free trial every year Historically to allow “catch-up” growth Appropriate times for a drug holiday Weekends Summer NOT during holidays or start of the school year
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All psychostimulants are controlled substances Methylphenidate, dextromethylphenidate amphetamine, dextroamphetamine, methamphetamine, and lisdexamfetamine are C- II WARNING: POTENTIAL FOR ABUSE Amphetamines have a high potential for abuse. Administration of amphetamines for prolonged periods of time may lead to drug dependence. Particular attention should be paid to the possibility of subjects obtaining amphetamines for non-therapeutic use or distribution to others and the drugs should be prescribed or dispensed sparingly. Misuse of amphetamines may cause sudden death and serious cardiovascular adverse events. - June 2009
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Straterra ® (atomoxetine) Tenex ® (guanfacine) Wellbutrin ® (bupropion) Catapres ® (clonidine) Risperdal ® (risperdone) Tricyclic antidepressants desipramine nortriptyline Zyprexa ® (olanzapine)* Geodon ® (ziprasidone)* Haldol ® (haloperidol)* Straterra ® (atomoxetine)* * = Short-term use (1-4 months)
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Increases norepinephrine (NOT DOPAMINE) in the brain synapse Side Effects Headache Insomnia Dry mouth Stomach upset Takes _____________ for max response
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Decreases norepinephrine May target impulsive behavior Takes ______ to begin working Side effects **Sedation** Dry mouth Low blood pressure – WARNING: rebound hypertension if abruptly stopped Slow heart beat Dizziness
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Growth suppression w/ stimulant use ADHD = 2-fold greater risk of substance abuse Cancer Helps student get straight A’s Decreases seizure threshold Causes Tourette syndrome Herbal/Alternative medications Pedi-Active Pycnogenol
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American Academy of Child and Adolescent Psychiatry – www.aacap.orgwww.aacap.org Attention Deficit Disorder Association – http://www.add.org/ http://www.add.org/ Parents Helping Parents: Family Resource Center for Children with Special Needs – http://www.php.com http://www.php.com National Resource Center on ADHD – http://www.help4adhd.org/ http://www.help4adhd.org/
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The nonmedical use of prescription drugs ranks ___ among the most abused class of drugs by adolescents _________ of teens do not see a great risk in trying prescription pain relievers without a prescription Rationale behind abuse Prescription medications are “safer” Readily available Less shame attached to using them Fewer side effects Less consequences if parents catch them
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1. Painkillers – Prescribed to treat pain codeine, oxycodone, fentanyl, morphine Brand Names: OxyContin, Percocet, Vicodin/Lortab, Duragesic 2. Depressants – Mainly prescribed to treat anxiety and sleep disorders Benzodiazepines, barbituates, etc. Brand Names: Klonopin, Soma, Valium, Xanax 3. Stimulants – Mainly prescribed to treat ADHD Amphetamines, methylphenidate, etc. Brand Names: Adderall, Concerta, Dexedrine, Ritalin
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Constricted pupils Slurred speech Flushed skin Sweating Lack of appetite Mood swings Personality changes Excessive energy Drowsiness Forgetfulness Acting secretive Losing interest in personal appearance Borrowing $/having extra cash Skipping classes Poor performance in school Prescription and over-the-counter medication signs
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Open discussion Parent-focused information and training Monitor teenagers internet use Watch for suspicious behaviors Keep track of prescription and over-the- counter medications Education within the school system Pharmacy involvement Medication guides Age restrictions for purchasing frequently abused over-the-counter medications Proper training of medical personnel
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Mark E. Schneiderhan, Pharm.D., BCPP Associate Professor University of Minnesota - Duluth Department of Pharmacy Practice and Pharmaceutical Sciences
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1. DiPiro, J. T., et al. Pharmacotherapy : a pathophysiologic approach. New York : McGraw-Hill, Medical Pub. Division, (2002). 2. Howard, M. M., R. M. Weiler, and J. D. Haddox. "Development and Reliability of Items Measuring the Nonmedical use of Prescription Drugs for the Youth Risk Behavior Survey: Results from an Initial Pilot Test." The Journal of school health 79.11 (2009): 554-60. 3. Salmeron, P. A. "Childhood and Adolescent Attention-Deficit Hyperactivity Disorder: Diagnosis, Clinical Practice Guidelines, and Social Implications." Journal of the American Academy of Nurse Practitioners 21.9 (2009): 488-97. 4. www.CADCA.org www.CADCA.org 5. www.theantidrug.com www.theantidrug.com 6. Schneiderhan, Pharm.D., BCPP, Mark E. "Attention Deficit Hyperactivity Disorder: Pharmacotherapy." University of Minnesota, Duluth, Duluth, MN. 14 Jan. 2010. Lecture.
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